Please note that the following information applies to Anthem Blue Cross and Blue Shield (Anthem) Indiana and Ohio local Commercial health plans.

 

Anthem implements pilot and modifies prior authorization requirements for admissions to in-network skilled nursing facilities (SNF).

 

  • Effective 11/16/2020 Anthem will allow a 5-day initial length of stay upon notification of an admission to an in-network SNF facility for local Commercial Indiana and Ohio member
    • Facility and physician must be in-network for the membe

 

  • Anthem will require notification of the SNF admission, which includes sending demographics and verification of benefits via the usual channe

 

  • Anthem will approve an initial 5-day length of stay without the need to provide clinical information.

 

  • SNF providers will need to submit the clinical information within two business days after the admission to aid in our members’ care coordination, discharge planning and member management. Note that prior authorization is still required but we allow the transfer to SNF, and then allow provider to send clinical within 2-days after the admission and prior to the last covered day for concurrent review.

 

  • Concurrent review will be required starting on day 5 of the SNF stay.

 

  • Anthem may apply monetary penalties such as a reduction in payment, for failure to provide timely notice of admission.

 

  • Indiana and Ohio will pilot this process through June 1, 2021 and will conduct random audits and monitor trends to evaluate the effectiveness of the pilot

 

*Note: This process does not apply to admissions to out-of-network (OON) SNF facilities.

 

Frequently Asked Questions

 

As a SNF provider, do I need to send information and notification to Anthem as I would normally do for a prior authorization?

Yes, notification is still required. However, you can notify Anthem of the admission and move the member without having to send in clinical or wait for an approval. It will be important to verify member benefits.

 

When do I need to submit clinical information?

For the initial SNF admission, no later than two business days after the admission and for continued stay, prior to the last covered day.

 

Does this apply to SNF, Inpatient (IP) Rehab and Long Term Acute Care (LTAC) admissions and related transportation (air or ground ambulance)?

This process is only applicable to the initial SNF admission. Follow standard prior authorization process for IP Rehab, LTAC and any related transportation.

 

For the SNF initial authorization of five days, will Anthem assign a level of care?

Anthem UM will assign Level of care once the clinical information is received from the SNF.

 

What if a member needs to be admitted for wound care and Intravenous (IV) antibiotics?

If a SNF has any concerns about the criteria for admission, they may still do the full prior authorization process.

 

If the physician and/or facility are out-of-network for the member, does this process apply?

No, the facility AND physician both need to be in-network. All out-of-network facilities and providers must follow the full prior authorization process.

 

What if I am uncertain if the member is a local Commercial member?

This process is applicable to local commercial accounts only.  It does not apply to Federal Employee Plan (FEP), National, Medicaid, Medicare, or Integrated Health Model (IHM). If you are uncertain, reach out to the Anthem dedicated nurse for your facility.

 

895-0121-PN-IN.OH



Featured In:
January 2021 Anthem Provider News - Ohio